RE: CDI Software -- Queries as part of the MR
1 -- Personally, I don't know the answer to that question. I suspect your organization's compliance and legal departments should participate in that conversation. In addition, your organization's policy on queries. Our queries done after discharge are part of the legal record, but the concurrent queries are not (but are retrievable).
2 -- there are enough ways for that information to leak, or for there to be a sufficient change in a documentation trend to suggest that there are query activities occurring.
Personally, even with queries that are not part of the record, am very concerned to ensure that queries are compliant and appropriate so that there is minimal risk of regulatory / compliance issues in the future. In addition, feel that there likely will be time where there is a reasonable chance that these queries will become 'discoverable'. Finally, I want our queries to be something well crafted and to be proud / satisfied to be ready to include in any such request if my organization decided to include.
Don
2 -- there are enough ways for that information to leak, or for there to be a sufficient change in a documentation trend to suggest that there are query activities occurring.
Personally, even with queries that are not part of the record, am very concerned to ensure that queries are compliant and appropriate so that there is minimal risk of regulatory / compliance issues in the future. In addition, feel that there likely will be time where there is a reasonable chance that these queries will become 'discoverable'. Finally, I want our queries to be something well crafted and to be proud / satisfied to be ready to include in any such request if my organization decided to include.
Don
Comments
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Sandy Beatty, RN, BSN, C-CDI
Clinical Documentation Specialist
Columbus Regional Hospital
Columbus, IN
(812) 376-5652
sbeatty@crh.org